Mandibular distraction osteogenesis in the pediatric patient

Failure of Mandibular Distraction Osteogenesis in Klippel- Feil Syndrome- 4: A Case Report of a Rare Syndromic Robin Sequence

Klippel-Feil syndrome-4 (KFS4), a rare autosomal recessive form of Klippel- Feil syndrome, is characterized by facial dysmorphism, nemaline myopathy, and short stature. Only 10 cases of KFS4 have been previously published in the literature. We report a novel case of a 1- month-old girl with known KFS4 and Robin Sequence (RS). At 2 months old, she underwent bilateral mandibular distraction osteogenesis to correct significant airway obstruction. Despite adequate mandibular advancement, the patient failed extubation twice and eventually required a tracheostomy. Due to the multiple anomalies present in KFS4, mandibular distraction osteogenesis may have a decreased likelihood of surgical success.

Novel Approach of Mandibular Distraction to Avoid Tracheostomy in KAT6B-related Gene Disorders

Previously, severe upper airway obstruction in patients with retrognathia and glossoptosis has been managed with tracheostomy. However, tracheostomy is associated with significant morbidity. In recent years, mandibular distraction has become an alternative management strategy in infants, but these applications have been limited to patient populations with retrognathia and glossoptosis. The authors present 2 unique cases of patients with KAT6B-related gene disorders, who present with a paradox of tongue-based airway obstruction in the absence of retrognathia. In both cases mandibular distraction osteogenesis with an obliquely oriented vector was successfully performed and both children avoided the need for tracheostomy.

Evaluation of parental and surgeon stressors and perceptions of distraction osteogenesis in pediatric craniofacial patients: a cross-sectional survey study

PURPOSE

There is a paucity of literature on how limitations of distraction osteogenesis (DO) are perceived by physicians and parents of pediatric patients. Specifically understanding which features of DO are most concerning to these two groups may better inform parent education, as well as direct improvements in distraction protocols and devices.

METHOD

Parents/guardians of patients (between January 2016 and October 2017) being treated with craniofacial distraction were recruited to complete a survey regarding level of stress (1 = not stressful, 9 = maximally stressful) associated with eight features of DO. Craniofacial surgeons completed a survey asking them to report (1) their personal level of stress and (2) their perceptions of parental stress regarding these same eight features of DO.

RESULTS

Thirty-five parents and 15 craniofacial surgeons completed the survey. The risk of the device getting infected was perceived as most stressful by parents (5.5 ± 2.3) followed by the device sticking through the skin (4.9 ± 2.6) and the second operation for removal (4.7 ± 2.3). These same three features also elicited the highest level of stress among surgeons. Surgeon-perceived parental stress regarding turning of the distractor (5.8 ± 1.5) was significantly higher than parent self-reported stress (4.2 ± 2.8, p = 0.042).

CONCLUSIONS

Both parents and surgeons perceive risk of device-associated infection, the protrusion of the device through the skin, and the requirement of a second operation for removal as the most stressful drawbacks of distraction. Infection reduction protocols, less obtrusive devices, and devices that do not require removal are potential targets for stress reduction.

Is Distraction Osteogenesis of the Irradiated Craniofacial Skeleton Contraindicated?

BACKGROUND

Craniofacial distraction osteogenesis (DO) is a common treatment modality today. Despite its numerous advantages, however, concerns have been expressed regarding the use of DO in the irradiated setting.

METHODS

A systematic review was performed to identify all published reports of patients who underwent DO of the irradiated craniofacial skeleton. The following parameters were of particular interest: postoperative complications, specifically, insufficient bone formation, fracture, and hardware exposure (intraoral and cutaneous), as well as the need for additional bone grafting.

RESULTS

The initial search retrieved a total of 183 articles of which 20 articles (38 patients) met predetermined inclusion criteria. The most common site of distraction was the mandible (76.3%). The median radiation dose was 50.7 Gy (range, 30-70 Gy). Bone defects ranged from 30 to 80 mm (median, 42.5 mm). Complications were encountered in 19 patients (50%), with insufficient bone formation being most common (9 patients; 23%). The overall incidence of complications was not significantly associated with radiation dosage (P = 0.79). The remaining procedural and demographic variables also failed to meet statistical significance when compared against the overall complication rate (P = 0.27-0.97).

CONCLUSION

The complication rate associated with craniofacial DO of the irradiated skeleton does not appear to be substantially higher than what is reported for DO in the nonirradiated setting. As such, patients should be offered this treatment modality, particularly in light of the fact, that it offers the option to decrease patient morbidity as well as treatment complexity.

Lehman syndrome: a new syndrome for pierre robin sequence

Lehman syndrome, or lateral meningocele syndrome, is characterized by facial dysmorphism, multiple lateral meningoceles, and skeletal abnormalities. Only nine cases have been described. We present a case of a 2-year-old boy presenting with micrognathia, glossoptosis, and hypertelorism as well as associated severe obstructive sleep apnea. He was submitted to bilateral mandibular distraction with external nonresorbable devices to correct Pierre Robin sequence (PRS). Later, multiple lateral meningoceles were identified, and a diagnosis of Lehman syndrome was made. Lehman syndrome must be considered in syndromic infants with PRS. Distraction osteogenesis is a safe procedure that is effective as a first choice in the treatment of patients with Lehman syndrome presenting with micrognathia.

Feeding and mandibular distraction osteogenesis in children with Pierre Robin sequence: a case series of functional outcomes

INTRODUCTION

In addition to upper airway obstruction, many patients with micrognathia and Pierre Robin sequence also have swallowing abnormalities and reflux. Many studies have demonstrated the effectiveness in alleviating the airway symptoms with mandibular distraction osteogenesis, but very few studies have focused on feeding and reflux outcomes.

METHODS

A retrospective chart review was performed to identify patients with Pierre Robin sequence who underwent mandibular distraction osteogenesis with completed pre- and post-operative upper gastroesophageal series and videofluoroscopic swallow assessments.

RESULTS

All six children in our series demonstrated significant improvements in both airway obstructive symptoms and feeding abnormalities. More specifically, all patients showed clinical and objective improvements in reflux and swallowing function after distraction surgery.

CONCLUSION

Objective and symptomatic improvements in swallowing function and reflux disease can be seen after mandibular distraction osteogenesis in children with Pierre Robin sequence.

A clinical narrative review of mandibular distraction osteogenesis in neonates with Pierre Robin sequence

INTRODUCTION

Neonatal upper airway obstruction secondary to micrognathia can be managed with conservative or surgical interventions. Traditionally, severe upper airway obstruction was managed with a tracheostomy. Although tracheostomy may be life saving, it is associated with high rates of complications and can lead to developmental problems. More recently, mandibular distraction osteogenesis has been utilized to relieve micrognathia associated airway obstruction.

METHODS

A clinical narrative review of the current literature was performed to evaluate the efficacy of mandibular distraction osteogenesis in neonates with Pierre Robin sequence.

OBJECTIVES

(1) To evaluate whether mandibular distraction osteogenesis can relieve the upper airway obstruction in micrognathic neonates and (2) to discuss and increase the awareness of various issues surrounding neonatal mandibular distraction procedures including preoperative workup, distraction protocols, and complications.

RESULTS

Mandibular distraction osteogenesis can be a safe and effective intervention in neonates diagnosed with Pierre Robin sequence with severe micrognathia and airway obstruction. Interestingly, in patients with additional complex syndromes, the airway obstruction was not consistently alleviated.

CONCLUSION

When conservative measures fail, mandibular distraction osteogenesis should be considered to obviate the need for a tracheostomy in newborns with micrognathia associated upper airway obstruction.

Mandibular distraction osteogenesis for pediatric airway management

PURPOSE

Mandibular retrognathia may cause upper airway obstruction in the pediatric patient due to tongue collapse and physical obstruction in the hypopharyngeal region. Mandibular distraction osteogenesis (DO) may be a useful treatment option to avoid tracheostomy. This study reviews 35 patients who underwent DO as treatment for concomitant jaw discrepancy and corrective airway management.

PATIENTS AND METHODS

Thirty-five consecutive patients, 20 male and 15 female, with airway obstruction were evaluated retrospectively using clinic and hospital records. The mean age was 3.5 months (range, 36 weeks' gestation to 4 years). The group consisted of patients with Pierre Robin sequence, Stickler syndrome, Opitz's syndrome, Down syndrome with obstructive sleep apnea, Goldenhar's syndrome, Treacher Collins syndrome, and mandibular retrognathia. All patients had obstruction limited to the upper airway related to severe retrognathia and posterior tongue-base displacement confirmed with direct laryngoscopy. All patients underwent mandibular DO to avoid or remove a tracheostomy and allow development of speech and normal feeding. Each patient underwent bilateral mandibular corticotomies and placement of 2 percutaneous Kirchner wires and extraoral distraction devices. Following a 0-day latency, DO was performed at 3 to 5 mm per day (mean: 4 mm per day) for a mean total of 22.5 mm (range, 15-32 mm). The mean consolidation period was 28 days (range, 20-42 days). Preoperative radiographs (lateral cephalometric radiograph and/or CT scan) were obtained in all cases preoperatively and at least 3 months postoperatively for analysis.

RESULTS

All patients experienced resolution of obstructive upper airway symptoms during the DO process. No patient required tracheostomy, and pre-existing tracheostomy devices were decannulated before DO completion. Apnea monitors failed to trigger in any patient postdistraction, and sleep studies were normal. The mean follow-up period was 9 months (range, 4-18 months). Radiographic analysis revealed the mean increase in posterior airway space was 12 mm. The mean decrease in overjet was 12 mm. Mandibular length increased a mean of 15 mm, and the sella-nasion-B point angle increased a mean of 16 degrees. DO complications included premature consolidation requiring manual refracture, hypertrophic scarring, device replacement, apertognathia with resolution within 8 to 12 weeks following device removal, and intraoral pin exposure. There were no cases of pin site infections or development of temporomandibular ankylosis.

CONCLUSION

Mandibular distraction osteogenesis is a viable option for the pediatric patient with upper airway obstruction due to mandibular deficiency to avoid a tracheostomy or other surgical intervention. Mandibular DO treats the etiology of the disease process and may allow for future growth.